radical cystectomy and urinary diversion: is there a …€¦ · orthotopic urinary diversion...

FACULTAT DE MEDICINA

Universitat Autogravenoma de Barcelona

Curs Acadegravemic 20102011

Treball de Recerca del Magravester Oficial ―INVESTIGACIOacute CLIacuteNICA APLICADA EN CIEgraveNCIES DE LA SALUT

RADICAL CYSTECTOMY AND URINARY DIVERSION IS

THERE A ROLE FOR BOWEL IN THE FUTURE

Student Marco Cosentino MD FEBU Departament of Surgery Fundaciograve Puigvert UAB - Universitat Autogravenoma de Barcelona Director Antoni Gelabert Mas PhD Full Professor of Urology Universitat Autogravenoma de Barcelona

INDEX

1) ABSTRACThelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 3

2) INTRODUCTIONhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 4

3) MATERIAL AND METHODShelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 9

4) RESULTShelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip10

5) DISCUSSIONhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 18

6) CONCLUSIONhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 20

7) REFERENCIEShelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 21

1 Abstract

3

1 ABSTRACT

Transitional cell carcinoma (TCC) of the bladder is the most frequent

malignancy of the urinary tract and its incidence is rising Depending on the stage of

the tumor the treatments for TCC of the bladder may vary from a conservative to a

radical surgery In case of invasive TCC of the bladder the gold standard treatment is

represented by radical cystectomy with extended lymphadenectomy and configuration

of a continent or non-continent pouch (conduitpouchneo-bladder) The reconstructive

step of radical cystectomy is achieved with the use of bowel segments to restore

bladder function Unfortunately the need for bowel has been universally considered to

be the prime source of postoperative complications (ie fistulas infections metabolic

disorders)

Since the 1960s urologists scientists and the industry have been trying to

obviate t he use of bowel with alternative synthetic and biologic materials to

reconstruct the bladder Despite the progress in technology and knowledge the

results have been quite discouraging Since we are facing a rise in life expectancy

with increase in both the elderly and bladder cancer population treatment

management in these patients represent an important challenge for present and future

urology

In this study we provide an analysis of problems deriving from using bowel for

urinary bladder diversion a comprehensive review of literature on pros and cons of

previous alloplastic and biologic models and a critical analysis of possible benefits

deriving from restoring urinary bladder function with an ideal synthetic prosthesis

2 Introduction

4

2 INTRODUCTION

The preservation or restitution of normal function although not always is

essential is certainly the most desiderable goal to be obtained after any surgical

procedure In this respect all operations for total removal of urinary bladder fail This

does not imply that the presentlsquos variety of urinary diversions after radical cystectomy

(RC) are not satisfactory (for there is much evidence to the contrary) but that these

operations do not attain the ideal of restoring the normal function of urinary bladder

and urinary excretion

More complex problems have always stimulated the creativity of surgeons

Urologists ―mission to the preservation of the urinary tract especially of the bladder

has guided the search for alternative methods of surgical reconstruction and

physiological rehabilitation using the intestine in many sophisticated surgical

techniques and as the ideal alternative for substitute the urothelium

During the last century since 1851 exactly urologic surgery has been

advanced by the development of a great number of new surgical procedures being

the removal of urinary bladder and the reconstruction of this part of urinary tract the

urological challenge most studied experimented and debated in literature Facing the

problem of a bladder which has lost his function owing to sclerosis of detrusor or in

case of tuberculosis or a bladder invaded by a tumor or any other problem which

could not permit the partial resection of the organ urologist were historically (and

are) reduced to perform radical cystectomy always asking themselves with some

distress ―And now Where can I place these 2 tubes

2 Introduction

5

A simple question with about twenty different valid and experimented

answers With the only exception of the vascular segment every kind of intestinal

segments was used as site of implant of ureters to reconstruct the urinary tract

including stomach ileum cecum colon sigma rectum and direct cutaneous

diversion without the interpose of bowel [1]

Nowadays the removal of the entire urinary bladder or the augmentation of his

capacity is obtained exclusively with the use of bowel While transitional cell

carcinoma of the bladder represents the most frequent indication to the removal of

the entire organ pediatric pathologies and functional ones are the most frequent

cause for augmentation or total substitution in no-oncological patients

TCC of the bladder is the most common malignancy of the urinary tract with a peak

incidence in the adult and elderly population [2] The gold standard treatment for

muscle-invasive and any non-muscle invasive TCC of the bladder even in the elderly

population is radical cystectomy [34] Nevertheless radical cystectomy is a major

surgical procedure performed with a curative intent and it is accompanied by a high

rate of complications (17ndash66) [5-7] its reconstructive part which counts on

sampling of bowel to restore urinary bladder function is generally considered the

main responsible for postoperative complications prolonged hospital stay and

readmission for complicationlsquos care Such complications have an effect on patientlsquos

physical and psychological sphere and increase costs to the National Health system

Since we are facing a rise in life expectancy [8] with increase in both the elderly and

bladder cancer population treatment management in these patients represent an

important challenge for present and future urology

The function of urinary bladder is to store urine at low pressure and to permit

voluntary voiding in absence of involuntary leakage of urine so from a mechanical

2 Introduction

6

point of view it can be considered as a sophisticated waterproof reservoir which fills

and empties at low pressure [9]

Since first cystectomy for bladder tumor performed in late 1887 by

Bardenheuer of Cologne the surgical challenge moved to replace appropriately the

function of this organ so progressively we have seen the developing of surgical

techniques with reconstruction of the urinary tract aimed to maintain control on

voluntary voiding and continence preserve renal function being aesthetically

acceptable and providing a good quality of life

One of the aspects that have attracted the attention of the industry in the past

and the present is tissue engineering for organ replacement The idea of replacing

bladder with a synthetic scuffle obviating the need for bowel for reconstruction and

therefore ideally diminishing complications during and after radical cystectomy has

always been attractive and source of investigation

Urinary bladder substitutes can be divided into two groups Biologic and

Alloplastic Biologic ones are all urothelial substitutes synthesized or developed from

living organism while alloplastic can be simply defined as all non-biological

materials

During these last two decades progress made in regenerative medicine cell

and stem-cell biology material sciences and tissue engineering enabled researchers

to develop cutting-edge technology leading to the ―construction of different tissue

(10-19) Urology in particular focused his interest in developing a substitute of

urothelium for both urinary bladder replacement and treatment of urethral stricture

On urinary bladder replacement object of this paper many were experimenting

cultures of regenerated multilayer urothelium being the Group of Atala the first

2 Introduction

7

publishing on an ―engineered bladder tissue created with autologous cells usable for

a cystoplasty [11]

While preliminary results on urothelial substitutes and firsts biologic neo-

bladders seems to be promising drawbacks as cell mutations biodegradability of the

scaffold the lack of direct vascular supply long-term outcomes of the ―transplanted

new organ the still elevated costs together with ethical and oncological

considerations were discouraging recommending further steps in this direction [13-

19] Not least these promising tissues substitutes of urothelium are unable to carry

out one of the main function of urinary bladder that of fill (be distensible) and void

(be contractile) (Fig1)

On the other side alloplastic materials joined progressively the daily clinical

practice of every speciality Urology in particular would not be the same without

devices such as bladder and ureteral catheters Since the Egyptians first used the

stalk of papyrus to drain urine thousands of years ago [20] alloplastic materials have

gradually become more useful comfortable and cheaper However while in most

specialties the use of permanent implants is possible (eg articular or vascular

prostheses) in urology this is not feasible yet due to infections and encrustations that

result from the continual exposure to urine

Despite different alloplastic and biologic prosthesis investigated during these

last 60 years the aim of replacing this ―simple organ has still not been targeted

Technical designs have become more sophisticated and new biomaterials with high

biocompatibility are now available but we are still looking for an alternative to bowel

sampling



2 Introduction

8



Figure 1 Construction of engineered bladder (From Reference 11) Scaffold seeded with cells (A) and engineered bladder anastamosed to native bladder with 4ndash0 polyglycolic sutures (B) implant covered with fibrin glue and omentum (C)

3 Material and methods

9

3 MATERIAL AND METHODS

A comprehensive review of literature was performed using the Medline

National Library of Medicine database and Google Scholar key-words used were

cystectomy and intestinebowel replacement bladder substitution urinary diversion

orthotopic neo-bladder complications and cystectomy uretero recto stomy uretero

sigma stomy uretero cutaneous diversion uretero bowel anastomosis costs and

cystectomy organ replacement artificial bladder alloplastic material biomaterial

tissue engineering We considered suitable for our review all historical models of

bladder substitute without the use of bowel emphasizing alloplastic models The

review focused on articles between January 1st 1851 and September 1st 2010 Only

articles in English were considered suitable for the study

4 Results

10

4 RESULTS

The first attempts of urinary diversion using a uretero-intestinal anastomosis

were performed in bladder exstrophy John Simon in late 1851 was the first that

suturing both ureters to the rectum caused a spontaneous fistula and subsequent

uretero-recto-stomy [21] Lloyd repeated this procedure the same year [22] Both

patients died for peritonitis after few days so the interest in this derivation was

diluted for many years

From an anatomical standpoint three alternatives are presently used after

cystectomy 1) Abdominal diversion such us uretero-cutaneo-stomy ileal or colonic

conduit and various forms of a continent pouch 2) Urethral diversion which includes

various forms of gastrointestinal pouches attached to the urethra as a continent

orthotopic urinary diversion (neobladder orthotopic bladder substitution) 3) Recto-

sigmoid diversions such as uretero-recto-stomy

Firstlsquos urinary bladder substitutions published included direct ureteral

anastomosis with the bowel without the interruption of his continuity and with

reconstructions such as uretero-recto or uretero-sigmoid or uretero-colon

anastomosis being uretero-sigmoid-stomy perhaps the oldest form of urinary

diversion It was realized primarily with a refluxive and then with an anti-reflux

connection of ureters into the bowel [2123] Most of the indications for this

procedure are now obsolete due to a high incidence of upper urinary tract infections

and the long-term risk of developing colon cancer [2425] Bowel frequency and

urge incontinence were additional side-effects of this type of urinary diversion

however it may be possible to circumvent by interposing a segment of ileum

between ureters and rectum or sigmoid in order to augment capacity and to avoid a

4 Results

11

direct interaction between urothelium and colonic mucosa together with faeces and

urine [26] The consideration on early and late complications impose to consider

different option in uretero-bowel technique opening of a new era in the surgery of

urinary diversions that of cutaneous diversion with an isolated segment of bowel

The first pioneer cited Verhoogan MD performed in the late 1908 a ―Ureteral

transplantation into an isolated segment of terminal ileum and ascending colon using

an appendicostomy as a urethra [27] All cutaneous diversions counts the

separation of an isolated segment of bowel from intestinal continuity (with his

vascular part) in which ureters are anastomized in his lower part while the upper is

directly anastomized to the skin of the abdominal wall Progressively cutaneous

diversions (non-orthotopic and non-continent) become and maybe they actually are

the standard treatment for Bladder Cancer (BC) in many Centres of the World a

―rapid technique with good functional and oncological long-term results

The ileal-conduit is still an established option with well-known results however

up to 48 of the patients develop early complications including urinary tract

infections pyelonephritis uretero-ileal leakage and stenosis [28] The main

complication in log-term follow-up studies are stoma complications in up to 24 of

patients and functional andor morphological changes of the upper urinary tract in up

to 30 of cases [29-31] An increase in complications was seen with increased

follow up in one recent serie of 131 patients followed for a minimum of 5 years

(median follow-up 98 months) [29] the rate of complications increased from 45 at

5 years up to 94 in those surviving longer than 15 years In this group 50 and

38 of patients developed upper urinary tract changes and urolithiasis respectively

Uretero-cutaneo-stomy is the simplest form of cutaneous diversion and itlsquos

considered as a safe procedure This surgical technique is preferred in older and

4 Results

12

compromised patients who need cystectomy and a no longer staying in operating

room [3233] Technically either one ureter to which the other shorter one is

attached end-to-side is connected to the skin (transuretero-uretero-cutaneo-stomy) or

both ureters are directly anastomosed to the skin Due to the small diameter of the

ureters stoma stenosis has been observed more often than in intestinal stoma [32]

In a recent retrospective comparison with short or median follow-up of 16 months the

diversion-related complication rate was considerably lower for uretero-cutaneo-stomy

compared to an ileal or colon conduit [34]

All this until last twenty years when the psychological problems secondary to

the distorted body image to difficulties in having a normal life because of the

presence of the external urinary-stoma and the need of the surgeon to propose

something better functionally and why not aesthetically lead urologists to the last

step in urinary bladder reconstruction that of the orthotopic neobladder

reconstruction This kind of reconstruction consist in the reconfiguration of an isolated

segment of bowel (most often the terminal ileum) placed then orthotopically and

directly anastomosed to ureters and urethra like in native bladder In several large

centres this has become the diversion of choice in most patients undergoing

cystectomy [35-37] The empting of the reservoir anastomosed to the urethra

requires abdominal straining intestinal peristalsis and sphincter relaxation Early and

late morbidity in up to 22 of the patients is reported [38-39] long-term

complications include diurnal (8-10) and nocturnal incontinence (20-30) uretero-

intestinal stenosis (3-18) urinary retention (4-12) metabolic disorders and

vitamin B12 deficiency in series with 1054 and more than 1300 patients [3640]

Urethral recurrence in neobladder patients seems rare (15-7 for both male and

female patients) [3641] These results indicate that the choice of a neobladder both

4 Results

13

in male and female patients does not compromise the oncological outcome of

cystectomy It remains debatable whether a neobladder is better for quality of life

compared to a non-continent urinary diversion [42-44]

Radical cystectomy (RC) with pelvic lymph node dissection represents the

most complex and physically demanding (for both patient and surgeon) urological

surgical procedure provides the best cancer-specific survival for muscle-invasive

urothelial cancer [4546] and is the standard treatment with 10 years recurrence-

free survival rates of 50-59 and overall survival rates around 45 [4547]

Unfortunately the need for bowel use has been universally considered to be

the prime source of postoperative complications with reported early complication (like

wound infection prolonged ileus urinary tract infections stoma necrosis necrosis of

diversion rectal injury fascial dehiscense ureteroileal leakage intestinal suture

leakage pelvicabdominal abscess bleeding fistula sepsis) rates of 16 to 61

late complications (urinary tract infections herniation diarrhea

dehidratationmetabolic disorders uretero-ileal stricture urethral stricture fistula

stoma stenosis lymphocele ileus vaginal prolapse severe reflux) rates of 24 to

66 metabolic complications (hyperchloremic acidosis hypochloremic acidosis

low vitamine B12 low folic acid) and perioperative mortality of 03 to 57 [5-7

28 34 48-52] (Tab 1)

4 Results

14

Table 1 Early postoperative complications reported in large series of radical cystectomy (2008ndash2009)

SERIES

(past decade around 100

patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008

Patients 96-6577 1142 358 258 104 281 Study period 1995-2005 2002-2006 1986-2005 1994-2003 1990-2005

Centres Single SIngle Single Multi (3) Single

Mortality at 30d 03-39 15 30 39 1 28 Minor complications 186-58 58 36 26 - 19

Major complications 49-255 9 13 11 - 24 One postoperative complications

ore more

19-57 64 49 34 24 44

Operating time h 49-64 64 5 38 5 - Estimated blood loss 600-1700 1000 600 1700 1500 -

Intraoperative transfusion rate (U)

and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL

Deep vein thrombosis 0-53 53 4 12 - 14

Pulmonary embolism 0-6 32 - 08 2 25 Septicaemia 0-96 66 - 12 - 96

Acute respiratory distress 0-38 35 1 - - 11

Pneumonia 0-78 39 4 19 4 78 Failure to wean from ventilatoron

ventilatorgt48h postop

0-26 - - - - -

Pulm emb clinical evidence of PE 0-19 - - - - - Reintubation 0-19 - - - - -

Cardiac (general) 0-13 23 4 - - -

Myocardial infarction 0-4 13 15 19 - 21 Dysrhythmia 0-72 72 2 19 - -

Cardiac arrest 0-13 - - - - -

Enterocolitis 0-8 34 - - - - Acute renal failure 0-7 - - - - -

UTI 0-128 99 - 5 1 128

Pyelonephritis 0-74 25 1 35 - - Metabolic imbalancedelirium 0-4 2 03 08 - 07

Skin ulcerpressure sore 0-06 04 - - - 04

PEG leakage 0-04 - - - - 04 Stroke (neurologic) 0-14 05 05 - 1 --

SURGICAL

Periop blood transfusion rate 0-23 - - - - - Postop haemorrhage transfusion

gt4U after operation

0-9 9 - - 1 14

Subileus (paralytic) 0-227 16 - 4 - 28 Constipation 0-12 26 12 - - -

GI (emesis gastritis ulcer) 0-161 14 3 - - -

Small bowel obstruction 0-7 7 - 08 4 - Enteroanastomosis leak 0-87 09 2 04 - 07

Required TotalParentNutrition 0-9 100 - - - -

GI bleed 0-13 13 - - - - Pyrexia of unknow origin 0-70 48 7 - - -

Pelvic lymphocoele with

intervention

0-35 13

Pelvic lymphocele (no intervent) 0-54 - - - - -

Precutaneous draiange 027 - - - - -

Peritonitis 0-08 Wound infection including superf 0-15 93 - 08 4 8

Deep (fascialmuscle) inf

Wound dehiscense 0-9 46 5 - 3 5

Secondary healing 0-8 - 3 - - -

With revision 0-5 - 2 - - -

Pelvic haematoma 0-2 - 1 - - - Pelvicabd abscess 0-44 44 - - - 11

Without revision 0-04 04 - - - - With revision 0-04 - - - - -

Diversion related 0-16 - - - - -

Urine leakpouch leakother 0-77 26 1 - 3 - Stomal necrosisstructure 0-17 04 - - - 07

Diversion necrosis 0-07 - - - - 07

Rectal injury 0-17 - - - - 07 Fistula 0-4 - 05 - - 04

Reoperation rate 0-17 3 10 8 8 -

Other 0-145 4 83 5 1 -

4 Results

15


obviate the use of bowel with alternative synthetic materials to reconstruct the

bladder Despite the progress in technology and knowledge the results have been

full quite discouraging

Various prostheses have been proposed for replacement of the urinary

bladder being silicone the most widely used material a plastic reservoir and

mechanical valves with abdominal drainage of urine via a silicone tube silicone

rubber prosthesis with transurethral drainage of urine a bistable latex prosthesis a

silicone rubber reservoir and an artificial urethra equipped with a sphincter

A variety of other prostheses which may entail the use of Gore-tex may or

may not be orthotopic and range from the simple to the sophisticated and from the

rigid to the distensible The most successful of the prostheses is that described by

Rohrmann et al and the last one derives from 1996 from the Mayo Clinic

Here we report one of the representative models of alloplastic bladder

published during this last 60 years

Bogash model [53] in this first model of artificial bladder presented in late

1960 by the pioneer in alloplastic substitution of the urinary bladder (M Bogash)

ureters drained into a silicone tube connected to the external abdominal wall Cons

Hydroureteronephrosis due to retractile scarring in ureteral anastomosis sites and

urinary infection secondary to the external connection ensued and none of the

devices survived for more than 4 weeks

One of the most sophisticated models was that known as the Mayo Clinic

model presented by OlsquoSullivan et al [54] (Fig 2) the model was based on negative

pressure drainage of urine from kidneys and active voiding It consisted of two

different shells an inner one of silicone (230 ml) surrounded by an external one of

4 Results

16

polysulfane (300 ml) Both were connected to the bladder neck with a 70-ml space

between them An internal spring mechanism generated negative pressure when

compressed facilitating filling and a similar pressurized mechanism facilitated

voiding Ureters were intubated with an 8-Fr silicone catheter reinforced with a nylon

spiral and the prosthesis drained under positive pressure into a silicon tube inserted

into the urethra Watertight anastomosis was ensured by Dacron reinforcement in

anastomosis sites Cons this too complex model failed inexorably within a few weeks

because of infections and technical failure of components

Another complex device but with the longest known life (more than 18 months

in two animals with no technical problems) was that known as the Aachen model

described by Rohrmann et al [55] It consisted of two separated subcutaneous and

compressible elastic reservoirs which drained urine from each kidney via a Dacron-

covered silicone tube placed through the renal parenchyma like an ―artificial ureter

Both reservoirs drained into the urethra through the interposition of a silicone tube

with a ―Y form external compression caused the positive pressure useful for voiding

with contemporaneous negative pressure within the reservoir to increase filling

4 Results

17

Figure 2 Anterior and lateral aspect of the Mayo clinic model (From reference 54)

5 Discussion

18

5 DISCUSSION

As highlighted by the above results many have already attempted to discover

the ideal alloplastic neo-bladder however this result has yet to come The main

causes of failure of all these models were deposition of connective tissue

encrustations infections hydroureteronephrosis leakage of urine from urethral or

ureteral anastomosis and problems related to biocompatibility being silicone the

most widely used material Despite its biocompatibility flexibility and durability it has

been shown that silicone is not the ideal material for bladder substitution because of

its low resistance to infection and encrustation A critical and careful analysis of all

the causes of failure might permit extrapolation of fundamental data and

development of guidelines for future models as listed by Desgrandchamps [56] It is

possible that scientific collaboration between engineers biologists and

biomaterialists with incorporation of recent developments and know-how in tissue

engineering would lead to technical and practical remedies to previous problems

and identification of all the features required for the ideal alloplastic bladder

Ideally a well-functioning reservoir for urine would be totally biocompatible and

impermeable store a sufficient volume of urine permit filling and voluntary voiding

without any pressure repercussions in the upper urinary tract avoid any leakage of

urine resist encrustation and infection be simple to implant and simple to replace in

case of malfunction and have an acceptable duration

A new alloplastic reservoir that meets these requirements could have

enormous clinicalpractical physical psychological and economic benefits The

need to restore bowel function is the principal reason why duration of surgery and

inpatient recovery time are lengthy Without the need for bowel surgery the operation

would entail simple reimplantation of ureters and urethra easily halving the duration

5 Discussion

19

of surgery and the recovery time Indirectly this would permit a reduction in drug

administration during surgery and hospitalization thereby saving money The

resultant quicker turnover of patients would also permit a reduction in the waiting list

for surgery Furthermore absence of use of bowel segments to restore bladder

function would potentially reduce readmission for potential attendant complications

In psychological terms orthotopic prosthesis would also have evident benefits

respect to external stoma [57-60] Avoiding bowel surgery physical activities would

be more rapidly restored with faster progression to adjuvant therapies on account of

a better physical condition The lack of need for bowel surgery would reduce too the

enormous economic cost incurred by every National Health System owing to use of

the instruments needed for bowel surgery (mechanical stapler suture needles etc)

use of devices such as external stoma appliancesbags (for patients with external

stoma) or of pads (in incontinent patients with orthotopic reconstruction) and the

need for subsequent interventions or readmission to the hospital Secondary the

identification of a biomaterial which can be used as a surrogate for urothelium could

be of value in the majority of the pediatric pathologies which require the use of bowel

(eg neurogenic bladder bladder exstrophy) Finally the identification of such

biomaterial resistant to infection encrustation and with an acceptable duration in

contact with urine may provide a new ―family of urological devices

The question remains as to whether and how a biomaterial with the above

described properties will become available for commercial and medical use since up

to now none is available

6 Conclusions

20

6 CONCLUSIONS

The pool of patients affected by bladder cancer is increasing also because of

the rise in life expectancy Radical cystectomy is the gold standard treatment for

muscle-invasive bladder cancer and bowel sampling for bladder substitution is still

the only reconstructive alternative for such patients Although artificial or biologic

substitution of the bladder would be desirable due to the physical psychological

technical and economic benefits an alloplastic or biologic material with compatible

properties to the human body has yet to be discovered So the answer to the

question proposed in the title (―is there a place for bowel in the future) must be

unequivocal ―no but not actually Indeed the repeated failure of this therapeutic

approach has been one of the factors prompting researchers to explore tissue

engineering and other alternatives to conventional enterocystoplasty Inter-

professional collaboration recent advances in technology and innovations in tissue

engineering may help in developing suitable alloplastic prosthesis Therefore both

urologists as well as engineers and the industry need to give this matter a serious

attention

7 Referencies

21

7 REFERENCIES 1 Stenzl A Bladder substitution Curr Opin Urol 1999 May9(3)241-5 2 Ferlay J Bray F Pisani P Parkin DM Globcan 2002 Cancer Incidence Mortality and Prevalence Worldwide IARC CancerBase No 5 version 20 Lyon IARCC Press 2004 3 Hollenbeck BK Miller DC et al Aggressive treatment for bladder cancer is associated with improved overall survival among patients 80 years old or older Urology 200464292ndash7 4 Miller DC Taub DA Dunn RL Montie JE Wei JT The impact of co-morbid disease on cancer control and survival following radical cystectomy J Urol 2003 Jan169(1)105-9 5 Studer UE Burkhard FC Schumacher M et al Twenty years experience with an ileal orthotopic low pressure bladder substitute-lessons to be learned J Urol 2006 Jul176(1)161-6 6 Novotny V Hakenberg OW Wiessner D et al Perioperative complications of radical cystectomy in a contemporary series Eur Urol 2007 Feb51(2)397-401 discussion 401-2 7 Konety BRAllreddy V Herr H Complications after radical cystectomy analysis of populations-based data Urology 2006 Jul68(1)58-64 Epub 2006 Jun 27 8 Dominguez LJ Galioto A Ferlisi A et al Ageing lifestyle modifications and cardiovascular disease in developing countries J Nutr Health Aging 2006 Mar-Apr10(2)143-9 9 Korossis S Bolland F et Al Tissue engineering of the urinary bladder considering structure-function relationships and the role of mechanotransduction Tissue Eng 2006 Vol 12 Num 4 10 Yu RN Estrada CR Stem cells a review and implications for urology Urology 2010 Mar75(3)664-70 Epub 2009 Dec 5 11 Atala A Bauer SB Soker S Yoo JJ Retik AB Tissue-engineered autologous bladders for patients needing cystoplasty Lancet 2006 Apr 15367(9518)1241-6 12 Mikos AG Herring SW Ochareon P et al Engineering complex tissues Tissue Eng 2006 Dec12(12)3307-39 13 Atala A Tissue engineering of human bladder Br Med Bull 2011 feb 15 [Epub ahead of print] 14 Orlando G Baptista P Birchall M et al Regenerative medicine as applied to solid organ transplantation current status and future challenges Transpl Int 2011 Mar24(3)223-232 doi 101111j1432-2277201001182x Epub 2010 Nov 10 15 Stanasel I Mirzazadeh M Smith JJ 3rd Bladder tissue engineering Urol Clin n Am 2010 Nov37(4)593-9 Epub 2010 Aug 11 16 Tanaka ST Thangappan R Eandi JA Leung KN Kurzrock EA Bladder-wall transplantationmdashlong-term survival of cells impications of bioengineering and clinical application Tissue Eng Part A 2010 Jun16(6)2121-7 17 Alberti C Tizzani A Piovano M Greco A Whatlsquos in the pipeline about bladder reconstructive surgery Some remarks on the state of the art Int J Artif Organs 2004 Sep27(9)737-43 18 Davis NF Callanan A McGuire BB Mooney R Flood HD McGloughlin TM Porcine extracellular matrix scaffolds in reconstructive urology an ex vivo comparative study of their biomechanical proprierties J Mech Behav Biomed Mater 2011 Apr4(3)375-82 Epub 2010 Nov 16

7 Referencies

22

19 Wood D Southgate J Current status of tissue engineering in urology Curr Opin Urol 2008 Nov18(6)564-9 20 Bitschai J The history of urology in Egypt Am J Surg 1952 Feb83(2)215-24 21 Simon J Ectopia vesicae (absence of the anteriors walls of the bladder and pubic abdominal parietes) Operation for directing the orifices of the ureters into the rectum temporary success subsequent death autopsy Lancet 2 568-570 1852 22 Lloyd Ectopia vesicae (absence of the anterior walls of the bladder) operation subsecuent death Lancet 2 370-372 1851 23 Coffey R Physiologic implantation of the severed ureter or common bile duct into the intestine JAMA 191156397 24 Azimuddin K Khubchandani IT Stasik JJ et al Neoplasia after ureterosigmoidostomy Dis Colon Rectum 1999 Dec42(12)1632-8 25 Gerharz EW Turner WH Kaumllble T et al Metabolic and functional consequences of urinary reconstruction with bowel BJU Int 2003 Jan91(2)143-9 26 Kaumllble T Busse K Amelung F et al Tumor induction and prophylaxis following different forms of intestinal urinary diversion in a rat model Urol Res 199523(6)365-70 27 Verhoogen J Neostomie Uretero-cecale Formation dlsquoune nouvelle poche vesicale et dlsquoun nouvel uretre Assoc Franc dlsquoUrol 12 352 1908 28 Nieuwenhuijzen JA de Vries RR Bex A et al Urinary diversions after cystectomy the association of clinical factors complications and functional results of four different diversions Eur Urol 200853 834-42 discussion 842-4 29 Madersbacher S Schmidt J Eberle JM et al Long-term outcome of ileal conduit diversion J Urol 2003 Mar169(3)985-90 30 Wood DN Allen SE Hussain M et al Stomal complications of ileal conduits are significantly higher when formed in women with intractable urinary incontinence J Urol 2004 Dec172(6 Pt 1)2300-3 31 Neal DE Complications of ileal conduit diversion in adults with cancer followed up for at least five years Br Med J (Clin Res Ed) 1985 Jun290(6483)1695-7 32 Deliveliotis C Papatsoris A Chrisofos M et al Urinary diversion in high-risk elderly patients modified cutaneous ureterostomy or ileal conduit Urology 2005 Aug66(2)299-304 33 Kilciler M Bedir S Erdemir F et al Comparison of ileal conduit and transureteroureterostomy with ureterocutaneostomy urinary diversion Urol Int 200677(3)245-50 34 Pycha A Comploj E Martini T et al Comparison of complications in three incontinent urinary diversions Eur Urol 200854825-32 35 World Health Organization (WHO) Consensus Conference in Bladder Cancer Hautmann RE Abol- Enein H Hafez K Haro I Mansson W Mills RD Montie JD Sagalowsky AI Stein JP Stenzl A Studer UE Volkmer BG Urinary diversion Urology 2007 Jan69(1 Suppl)17-49 36 Hautmann RE Volkmer BG Schumacher MC et al Long-term results of standard procedures in urology the ileal neobladder World J Urol 2006 Aug24(3)305-14

7 Referencies

23

37 Stein JP Skinner DG Radical cystectomy for invasive bladder cancer long-term results of a standard procedure World J Urol 2006 Aug24(3)296-304 38 Stein JP Dunn MD Quek ML et al The orthotopic T pouch ileal neobladder experience with 209 patients J Urol 2004 Aug172(2)584-7 39 Abol-Enein H Ghoneim MA Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation experience with 450 patients J Urol 2001 May165(5)1427-32 40 Stein JP Skinner DG Results with radical cystectomy for treating bladder cancer a reference standardlsquo for high-grade invasive bladder cancer BJU Int 2003 Jul92(1)12-7 41 Stein JP Clark P Miranda G et al Urethral tumor recurrence following cystectomy and urinary diversion clinical and pathological characteristics in 768 male patients J Urol 2005 Apr173(4)1163-8 42 Gerharz EW Maringnsson A Hunt S et al Quality of life after cystectomy and urinary diversion an evidence based analysis J Urol 2005 Nov174(5)1729-36 43 Hobisch A Tosun K Kinzl J et al Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion Semin Urol Oncol 2001 Feb19(1)18-23 44 Porter MP Penson DF Health related quality of life after radical cystectomy and urinary diversion for bladder cancer a systematic review and critical analysis of the literature J Urol 2005 Apr173(4) 1318-22 45 Meyer JP Blick C arumaunaygam N et al A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy revisiting the initial experience and results in 104 patients BJU Int 2009 Mar103(5)680-3 Epub 2008 Dec 2 46 Cookson MS Chang SS Wells N Parekh DJ Smith JA Jr Complications of radical cystectomy for nonmuscle invasive disease comparison with muscle invasive disease J Urol 2003 Jan169(1)101-4 47 Colombo R Editorial comment on Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology Eur Urol 2009 Jan55(1)175-6 Epub 2008 Jul 18 48 Chang SS Cookson MS et Al Analysis of early complications after radical cystectomy results of a collaborative pathaway J Urol 2002167 2012 49 Hollenbeck BK Miller DC et Al Identifing risk-factors for potentially avoidable complications following radical cystectomy J Urol 2005174 1231 50 Quek ML Stein JP et AL A critical analysis of perioperative mortality from radical cystectomy J Urol 2006175 886 51 Fairey A Chetner M et Al Associations among age comorbidity and clinical outcome after radical cystectomy results from the Alberta Urology Institute radical cystectomy database J Urol 2008180 128 52 Bostrom PJ Kossi J et Al Risk factors for mortality and morbidity related to radical cystectomy BJU Int 2009103 191 53 Bogash M Kohler FP Scott RH Murphy JJ Replacement of the urinary bladder by a plastic reservoir with mechanical valves Surg Forum 196010900-3

7 Referencies

24

54 OlsquoSullivan DC Barrett DM Prosthetic Bladder in vivo studies on active negative-pressure-driven device J Urol 1994 Mar151(3)776-80 55 Rohrman D Albrecht D Hannapel J Gerlach R Schwarzkopp G Lutzeyer W Alloplastic replacement of the urinary bladder J Urol 1996 Dec156(6)2094-7 56 Desgrandchamps F Griffith DP The artificial bladder Eur Urol 1999 Apr35(4)257-66 57 Hardt J Filipas D Hohenfellner R Egle UT Quality of life in patients with bladder carcinoma after cystectomy first results of a prospective study Qual Life Res 2000 Feb9(1)1-12 58 Mansson A Davidsson T Hunt S Mansson W The quality of life in man after radical cystectomy with a continent cutaneous diversion or orthotopic bladder substitution is there a difference BJU Int 2002 Sep90(4)386-390 59 Kulaksizoglu H Toktas G Kulaksizoglu IB Aglamis E Unluer E When should quality of life be measured after radical cystectomy Eur Urol 2002 Oct42(4)350-5 60 Palapattu GS Haisfield-Wolfe ME Walker JM BrintzenhofeSzoc K trok B Zabora J Shoenberg M Assessment of perioperative psychological distress in patients undergoing radical cystectomy for bladder cancer J Urol 2004 Nov172(5Pt1)1814-7

INDEX

1) ABSTRACThelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 3

2) INTRODUCTIONhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 4

3) MATERIAL AND METHODShelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 9

4) RESULTShelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip10

5) DISCUSSIONhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 18

6) CONCLUSIONhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 20

7) REFERENCIEShelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 21

1 Abstract

3

1 ABSTRACT










disorders)







urology





2 Introduction

4

2 INTRODUCTION






















2 Introduction

5


























2 Introduction

6

















materials








2 Introduction

7


a cystoplasty [11]





















sampling



2 Introduction

8





9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


1 Abstract

3

1 ABSTRACT










disorders)







urology





2 Introduction

4

2 INTRODUCTION






















2 Introduction

5


























2 Introduction

6

















materials








2 Introduction

7


a cystoplasty [11]





















sampling



2 Introduction

8





9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


2 Introduction

4

2 INTRODUCTION






















2 Introduction

5


























2 Introduction

6

















materials








2 Introduction

7


a cystoplasty [11]





















sampling



2 Introduction

8





9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


2 Introduction

5


























2 Introduction

6

















materials








2 Introduction

7


a cystoplasty [11]





















sampling



2 Introduction

8





9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


2 Introduction

6

















materials








2 Introduction

7


a cystoplasty [11]





















sampling



2 Introduction

8





9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


2 Introduction

7


a cystoplasty [11]





















sampling



2 Introduction

8





9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


2 Introduction

8





9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24



9












4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

10

4 RESULTS
























4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

11


























4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

12


























4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

13



















28 34 48-52] (Tab 1)

4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

14


SERIES


patients)

SUMMARY SHABSIGH

et al 2009

NOVARA

2009

BOSTROumlM

et al 2009

MEYER et

al 2009

NIEUWENHU

IJZEN et al

2008





ore more

19-57 64 49 34 24 44



and perioperative

1-66 66 15 29 2 (in 82) -

MEDICAL






0-26 - - - - -






UTI 0-128 99 - 5 1 128




SURGICAL



0-9 9 - - 1 14







intervention

0-35 13















Other 0-145 4 83 5 1 -

4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

15


























4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

16

















4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


4 Results

17


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


5 Discussion

18

5 DISCUSSION

























5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


5 Discussion

19























6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


6 Conclusions

20

6 CONCLUSIONS















attention

7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


7 Referencies

21


7 Referencies

22


7 Referencies

23


7 Referencies

24


7 Referencies

22


7 Referencies

23


7 Referencies

24


7 Referencies

23


7 Referencies

24


7 Referencies

24


radical cystectomy and urinary diversion: is there a …€¦ · orthotopic urinary diversion...

Documents